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Improving Opioid Prescribing Practices

Opioids are prescribed at high and increasing rates in the United States both within and outside VA; over 23 percent of VA patients received an opioid prescription in FY10. Opioids are considered a core pain management tool, but long-term effectiveness of opioid therapy for chronic pain is untested, and opioid use is associated with a number of serious risks, including death from unintentional overdose or suicide, sedation-related accidents, and medication interactions. The VA/DOD Clinical Practice Guideline for Opioid Therapy for Chronic Pain (CPG) outlines care practices designed to reduce the risks and increase the effectiveness of opioid therapy. But guideline recommended practices are not consistently followed.

HSR&D/QUERI has supported several studies designed to inform and support VA efforts to improve the safety and effectiveness of opioid therapy for chronic pain. We describe studies that focused on three strategies for improving the quality of opioid therapy in VA: 1) improve point-of-care clinical decision-making around opioids by providing CPG-based patient-specific recommendations, tailored data, and tools to primary care providers; 2) increase understanding of patient experience and behaviors around opioid therapy to develop better methods of communicating with patients and managing their opioid-related risks; and 3) develop measures of adherence to CPG-recommended practices for opioid therapy to identify variation in clinical practice, and motivate and guide quality improvement efforts.

Improving Point-of-Care Clinical Decision Support

Primary care clinicians report feeling inadequately trained to deliver safe and effective pain management, but are being increasingly relied upon to treat chronic pain and are frequent prescribers of opioid therapy. To support primary care clinicians in opioid prescribing, we iteratively developed and tested a computerized decision-support system based on the CPG and the core ATHENA-Decision Support System software architecture. Development of ATHENA-Opioid Therapy (OT) involved operationalization of the CPG content with key CPG authors, design of a graphical user interface with pain and primary care clinic staff input, and lab-based and in-clinic usability testing with providers.¹ ATHENA-OT includes patient-specific alerts and instructions on how to change prescriptions, filtered and highlighted opioid-relevant patient-data, and tools to facilitate CPG-recommended practices. Usability and implementation evaluation suggested a need for methods to coordinate PACT and specialty team-based management, increase prioritization of good pain management practices, and support clinician communication around emotion-laden topics.

Understanding Patient Behaviors and Experience

To understand and identify risk factors for patients using opioid medications in problematic ways, we conducted structured interviews with 191 Veterans who had at least one opioid prescription in the last year. Pain and physical functioning, prescription drug use, substance abuse history, and mental health conditions were assessed. Findings confirmed previous research identifying existing substance use and mental health problems as risk factors, but also identified novel and straightforward approaches to address behaviors in patients to improve opioid use. For example, clinicians prescribe—and patients use—different strategies for taking opioid medications. Symptomatic use of opioid medications—in response to pain or distress—was most common, but associated with worse pain-related mental health. Patients who used opioid medications on a schedule reported better pain-related mental health. While literature has focused on patient overuse of opioids, in our sample, problematic underuse of opioid medications was more prevalent (20 percent) than overuse (9 percent).² Lastly, most patients saved their extra medications, and roughly one-third reported borrowing or sharing opioid medication at least once. These findings suggest new interventions, including modifying prescription instructions and monitoring use and disposal of medication that could improve safety and effectiveness.

Motivating and Guiding Opioid Therapy Quality Improvement

A team of VA leadership, clinicians, and measurement experts developed metrics to assess CPG adherence using VA administrative data.³ These metrics assess use of care practices to improve opioid safety and effectiveness including use of urine drug tests, managing patients with substance use disorders in addiction specialty care, avoiding co-prescription of sedative medications, avoiding sole reliance on opioid therapy for pain management, and serious adverse events. Some practices vary widely across VA facilities; for example, while urine drug testing is conducted routinely at some facilities others rarely use this practice. Other measures indicate non-optimal, but relatively consistent practice patterns across facilities, such as co-prescribing sedative and opioid medications. These measures are being monitored by VA Central Office and emphasize the need for development and targeting of effective interventions to improve opioid prescribing practices.

Together, these studies have increased our understanding of the current challenges and strengths of VA pain management practice. Findings suggest opportunities for quality improvement and development of new interventions to improve safety and effectiveness of opioid prescribing.

References

1. Trafton, J.A. et al. "Evaluation of the Acceptability and Usability of a Decision Support System to Encourage Safe and Effective Use of Opioid Therapy for Chronic, Non-Cancer Pain by Primary Care Providers," Pain Medicine 2010; 11(4):575-85.
2. Lewis, E. et al. "Reasons for Under-use of Prescribed Opioid Medications by Patients in Pain," Pain Medicine 2010; 11(6):861-71.
3. Midboe, A.M. et al. "Measurement of Adherence to Clinical Practice Guidelines for Opioid Therapy for Chronic Pain," Translational Behavioral Medicine 2012; 2:57-64.